Implementation Research for Vulnerable Women in South Africa

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DESCRIPTION (provided by applicant): Recent estimates of HIV prevalence among women in South Africa exceed 40%. Vulnerable women living with HIV or at risk of HIV in South Africa face barriers to protecting themselves because of gender-based violence (GBV) and alcohol and other drug (AOD) use. AOD use reduces the likelihood of testing for HIV and access to antiretroviral therapy (ART) among those who are tested and reduces adherence among those who are on ART. AOD use also increases behaviors that may transmit HIV. Despite the pervasive negative impact of AOD use among women living with HIV, very few health clinics that provide HIV counseling and testing (HCT) or antenatal care, substance abuse rehabilitation clinics, or HIV clinical care use evidence- based interventions (EBIs) to address this problem. Since 2001, we have adapted and conducted a comprehensive EBI for women, the Women's Health CoOp (WHC), that addresses alcohol AOD use, sexual risk, and GBV. It incorporates a personalized action plan complete with linkages for health services like ART, substance abuse treatment, or other environmental needs such as housing. The WHC was listed in the USAID Compendium of Gender Studies in Africa. We packaged this intervention for training of trainers and it is poised to be integrated into usual care to help address many of the issues facing vulnerable women. Consequently, our proposal is the next logical step to ensure its success before a larger scale-up can occur. This proposed R01 project seeks to develop and test an implementation strategy for integrating an EBI. We will use formative methods to collaborate with community women, our Community Advisory Boards, clinic staff, and administrators to develop and implement a marketing plan that addresses the challenges of integrating the WHC into usual care health centers where antenatal or HCT services are provided and into substance abuse rehabilitation centers (rehab). The findings from the formative work will guide the implementation in a series of iterative pilot studies using a stepped-wedge design to evaluate the implementation and patient outcomes. Specific Aims: Our specific aims include the following: Aim 1. Develop, implement, and assess the appropriateness of a marketing plan to facilitate entry into health centers and rehab sites for the implementation of the WHC. Aim 2. Deliver the WHC via a stepped-wedge design across health and rehab clinics to evaluate implementation (acceptability, adoption, cost, fidelity, penetration, and sustainability) and service outcomes (comprehensive services and timely service linkages). Aim 3. Assess WHC patient outcomes (effectiveness, satisfaction) at 6-month follow-up. Implementing an EBI in usual care settings to reach more vulnerable AOD-using women who are HIV+ has potentially high public health impact if it can be implemented successfully and shown to be effective and sustainable in real-world settings.